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07/31/2002 II 25 2094683433 FIFTH FLOOR PAGE 02 <br /> San Joaquln County EnvF;7 <br /> JOB ADDRESS: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License# Expiration Date /-:Loo Z/ <br /> Date a� Contractor �.E'�C�r /Z-4-/M� � �� <br /> Signature Tale :7:701VJ- <br /> Printed name lie /Z 2ZLk <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br /> have and will maintain a certificate of consent to self-insure for workers' compensation as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued My workers compensation insurance <br /> carrier and policy numbers are Il <br /> Carrier �'111�/✓!%�iili�-p olicy Number 0 23 <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers compensation laws of California, and agree that if I <br /> should become subject to the werkers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply/with those provisions <br /> Date `��a /0 _Signature. 64*4JA�-7 <br /> Printed Name <br /> WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S100,000). IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> ti <br /> 1, (C-57 licensed authorized representative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf I understand this authorization is valid for <br /> one (1)year and is limited to the work plan dated on the front page of this application <br /> i <br />